Those who follow Medicare's reporting requirements and are top performers relative to their peers could see a more than 20% increase in payment per bill by 2022, said Michael Powe, vice president of reimbursement and professional advocacy for the AAPA.

"We're talking real money here, and you can't afford to leave it on the table," Powe said.

The AAPA is also urging the Centers for Medicare and Medicaid Services to tweak some aspects of the program to prevent PAs from becoming invisible to billers and coders.

Certain practitioners may be exempt from MIPS, including those who are new to Medicare and those who meet a "low-volume threshold" of fewer than 100 Medicare patients per year, or less than $30,000 in payments annually. Clinicians enrolled in a qualifying advanced APM are also exempt, Powe said.

The level of bonuses and penalties rises each year for clinicians enrolled in the program. While 2017 is the first reporting year, performance adjustments will not begin until 2019, with losses/gains jumping to 4% in 2019; 5% in 2020; 7% in 2021; and 9% in 2022.

Those who rank in the "upper echelons" of performance will have the opportunity to gain 3 times the bonus (i.e. 27% in 2022).

Advanced APMs

Clinicians who qualify to be in an advanced APM receive a lump-sum 5% incentive payment from 2019 through 2024 and a higher annual payment beginning in 2026.

This pathway requires that practices take a certain degree of risk, use certified electronic health record technology, and adopt a higher level of transformation.

Powe highlighted several concerns about the new reimbursement structure.

First, PAs who bill under a collaborating physician may appear to have seen only a fraction of the patients they actually encountered and earned fewer Medicare dollars than is accurate. Consequently, these clinicians may fall under the low volume threshold and be excluded from the program.

"Just because everything is billed under the doc, doesn't mean the doc did all the work," Powe said.

Identifying the "rendering provider" by using a National Provider Identifier (NPI) number, for instance, could help track PA services, he noted -- something the AAPA has asked CMS to change.

In addition to losing potential bonus dollars, if the mechanism isn't tweaked, these clinicians won't be listed on Physician Compare -- the public-facing website that tracks all providers who qualify for the QPP, which is expected to influence patient and employer decisions -- and will become virtually invisible to patients and possible employers.

Powe also stressed that billers, vendors, and other staff will need proper training in how to correctly bill and code for PAs.

Second, the AAPA sees the lag-time in performance metrics reporting as unhelpful. Clinicians who submit metrics to CMS in 2017 will not receive a fine or bonus until 2019, Powe explained.

"It doesn't make sense to have to wait a year-and-a-half or two years before you know if in fact you did it right," he said.

The AAPA wants to tighten that window so that clinicians will know sooner if they're meeting the CMS guidelines.

Powe also spoke of barriers for PAs within Accountable Care Organizations (ACOs): "Right now the federal rules say that the patient has to have at least one contact with a physician in order to be attributed to an ACO."

If a PA is working for the same ACO as a physician, and is entirely responsible for an individual patient's care, the AAPA thinks that attribution should be enough, he said.

One final concern relates to risk adjustment. Medicare is developing a weighting scale to try to even out the reporting metrics for those who see the most challenging patients.

For example, a PA in one poor urban community might see more low-income patients who have little access to transportation and nutritious foods, while another PA may work in a neighborhood where most patients have gym memberships and can easily afford fresh food.

Powe worried that because of these challenges some providers may "cherry-pick" only the healthiest patients to enhance their final scores.